Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers’ voices and experiences

The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies. Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions. We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%). Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better

A survey on the use of continuous positive airway pressure in newborn care in Kenya in 2017–2018

Background Globally, complications of preterm birth are the leading cause of under-5-mortality. Respiratory distress syndrome (RDS) is a common and life-threatening complication among preterm infants. Continuous positive airway pressure (CPAP) is a relatively simple and effective intervention that is recommended for RDS treatment. However, appropriate infrastructure and processes are required to ensure that it is used safely, effectively and sustainably. This study describes how CPAP was used in newborn care in Kenya between 2017–2018. Our aim was to identify enablers, barriers and gaps in CPAP use. Methods A cross-sectional survey was carried out across all newborn baby units in Kenya between 2017–2018, as part of a evaluation of CPAP use in newborn care. Descriptive statistics were used to analyze the quantitative data. Results Twenty-three hospitals across 15 (32%) of the counties in Kenya were providing CPAP in newborn care. The survey was conducted in 19 hospitals, amounting to 83% of all hospitals providing CPAP in newborn care in the country. Sub-county (level 4) and county (level 5) referral had fewer resources (i.e., trained staff, infrastructure and equipment) than the national referral (level 6) and private hospitals. In addition, there was a wide variation in the CPAP devices used and the resources for supporting CPAP use across different hospitals. Conclusion We found access to CPAP for neonates with RDS was inequitable in Kenya. There were also disparities in the availability of resources, personnel, and guidelines to support its implementation. Lack of standardisation of CPAP use in newborn care was especially evident in the public sector. To optimise coverage and standardisation of CPAP use in newborn care in Kenya, our results support ongoing partnerships to strengthen public and private healthcare sectors involving the implementation of strategies to improve infrastructure for newborn care, train and retain staff, and provide additional equipment

Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360

Background: Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. Methods: We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. Findings: We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. Conclusion: Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical

Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania

Background: Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. Methods: A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2+, scoring items on readiness to provide WHO level-2+clin‑ ical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. Results: Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2+scoring. Sixtyeight neonatal units across four countries had median standards-based scores of 51% [IQR 48–57%] at baseline, with variation by country: 62% [IQR 59–66%] in Kenya, 49% [IQR 46–51%] in Malawi, 50% [IQR 42–58%] in Nigeria, and 55% [IQR 53–62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18–40%] with governance highest scoring [76%, IQR 71–82%]. For level-2+scores, the overall median score was 41% [IQR 35–51%] with vari‑ ation by country: 50% [IQR 44–53%] in Kenya, 41% [IQR 35–50%] in Malawi, 33% [IQR 27–37%] in Nigeria, and 41% [IQR 32–52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring interven‑ tion [58%, IQR 50–75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8–42%]. In both methods, overall scores were low (\u3c50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2+scoring. No neonatal unit achieved high scores of\u3e75%. Discussion: Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (\u3e75%). Government-led quality improvement teams can use these summary scores to identify areas for health sys‑ tems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes

Small and sick newborn care: changes in service readiness scoring between baseline and 2023 for 65 neonatal units implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania

Health Facility Assessments (HFAs) are important for measuring and tracking service readiness for small and sick newborn care (SSNC). NEST360 Alliance aims to reduce neonatal mortality in four countries (Kenya, Malawi, Nigeria, Tanzania). NEST360 and UNICEF facilitated HFA tool design with ministries of health in four African countries and developed two complimentary approaches to summarize readiness. Using the NEST360/UNICEF HFA tool, we collected data, developed two service readiness scoring approaches for SSNC (standards-based scoring by adapted World Health Organization (WHO) health system building blocks (HSBBs) and assessing service readiness across the health system, and level-2+ scoring by WHO clinical interventions), and applied across 65 neonatal units implementing NEST360. Service readiness change was assessed between baseline (Sept 2019-March 2021) and follow-up HFA (May-July 2023). For each neonatal unit, a percentage difference score was computed between baseline and 2023 HFA scores. Scores were calculated for each neonatal unit as the unit of analysis, and disaggregated by HSBB, clinical intervention, and sub-modules. Data from 65 neonatal units were analysed, i.e., 36 in Malawi, 13 in Kenya, 7 in Tanzania, and 9 in Nigeria. Median time between baseline and 2023 HFAs was 31 months [IQR 29–34 months]. Median baseline and 2023 scores were 41% [IQR 35–52%] and 55% [IQR 46–62%] respectively with 14% median score change [IQR 4–18%] for level-2+ scores. For standards-based scores, median baseline and 2023 scores were 51% [IQR 48–58%] and 60% [IQR 54–66%] respectively with a 9% median score change [IQR 3–11%]. Hospitals in Tanzania [Median 24%, IQR 16–30%] and Nigeria [Median 28%, IQR 17–30%] showed greater improvements on average for level-2+ scores compared to hospitals in Kenya and Tanzania. Data on changes in service readiness scores can be used to track service readiness over time, benchmark between hospitals, identify gaps, and assess progress towards newborn targets

Developing context-sensitive, comprehensive newborn care protocols: integrating technologies with clinical care pathways for level 2 newborn units in Kenya

BackgroundAn estimated 2.3 million neonates die worldwide each year (47% of under-five mortality), with 75% occurring during the first week of life. The burden is highest in sub-Saharan Africa (n/N = 27/1000 neonatal mortality rate) and largely results from preventable conditions, such as prematurity, birth asphyxia, and infections. The Newborn Essential Solutions and Technologies (NEST360) programme supports health systems in resource-constrained settings (RCSs) through appropriate technologies, training, data use, and mentorship to reduce preventable neonatal deaths. The NEST360 programme, in partnership with the Kenya Ministry of Health, both inspired and enabled the development of evidence-based comprehensive newborn care protocols (NBU-Protocols) and a dissemination training. This article documents the development of the protocols and lessons learned to inform scalable solutions for RCSs.MethodsThe NBU-Protocols and their dissemination programme were developed through a review of evidence on the care for small and sick newborns, followed by iterative feedback from stakeholders, including frontline health workers, academics, and researchers. The protocols were piloted and further revised following a national stakeholder workshop.ResultsThe NBU-Protocols comprise three chapters: clinical care pathways; standard operating procedures for NBU equipment; and step-by-step instructions for common clinical procedures performed in level 2 NBUs. The protocols were grounded in family-centred care and infection prevention and control principles. They were presented as e-protocols with hyperlinks, bookmarks, and cross-references to facilitate ease of use. The protocols dissemination programme, called Newborn ETAT+, was a three-pronged training approach taught by experts in the following groups: clinical care pathways by paediatricians; equipment parts and functions by biomedical engineers; and equipment use and care by NBU nurses. A third of the training was dedicated to interactive lectures, with the remainder focussed on demonstrations, simulations, clinical procedures on manikins, and hands-on experience with NBU equipment.ConclusionsThe NBU-Protocols and training model highlight the potential of context-specific, multidisciplinary strategies to improve collaboration and standardise care in NBUs in low- and middle-income countries (LMICs)

Blood culture versus antibiotic use for neonatal inpatients in 61 hospitals implementing with the NEST360 Alliance in Kenya, Malawi, Nigeria, and Tanzania: a cross-sectional study

Background: Thirty million small and sick newborns worldwide require inpatient care each year. Many receive antibiotics for clinically diagnosed infections without blood cultures, the current ‘gold standard’ for neonatal infection detection. Low neonatal blood culture use hampers appropriate antibiotic use, fuelling antimicrobial resistance (AMR) which threatens newborn survival. This study analysed the gap between blood culture use and antibiotic prescribing in hospitals implementing with Newborn Essential Solutions and Technologies (NEST360) in Kenya, Malawi, Nigeria, and Tanzania. Methods: Inpatient data from every newborn admission record (July 2019–August 2022) were included to describe hospital-level blood culture use and antibiotic prescription. Health Facility Assessment data informed performance categorisation of hospitals into four tiers: (Tier 1) no laboratory, (Tier 2) laboratory but no microbiology, (Tier 3) neonatal blood culture use \u3c 50% of newborns receiving antibiotics, and (Tier 4) neonatal blood culture use \u3e 50%. Results: A total of 144,146 newborn records from 61 hospitals were analysed. Mean hospital antibiotic prescription was 70% (range = 25–100%), with 6% mean blood culture use (range = 0–56%). Of the 10,575 blood cultures performed, only 24% (95%CI 23–25) had results, with 10% (10–11) positivity. Overall, 40% (24/61) of hospitals performed no blood cultures for newborns. No hospitals were categorised as Tier 1 because all had laboratories. Of Tier 2 hospitals, 87% (20/23) were District hospitals. Most hospitals could do blood cultures (38/61), yet the majority were categorised as Tier 3 (36/61). Only two hospitals performed \u3e 50% blood cultures for newborns on antibiotics (Tier 4). Conclusions: The two Tier 4 hospitals, with higher use of blood cultures for newborns, underline potential for higher blood culture coverage in other similar hospitals. Understanding why these hospitals are positive outliers requires more research into local barriers and enablers to performing blood cultures. Tier 3 facilities are missing opportunities for infection detection, and quality improvement strategies in neonatal units could increase coverage rapidly. Tier 2 facilities could close coverage gaps, but further laboratory strengthening is required. Closing this culture gap is doable and a priority for advancing locally-driven antibiotic stewardship programmes, preventing AMR, and reducing infection-related newborn deaths

Hypothermia amongst neonatal admissions in Kenya: a retrospective cohort study assessing prevalence, trends, associated factors, and its relationship with all-cause neonatal mortality

Background: Reports on hypothermia from high-burden countries like Kenya amongst sick newborns often include few centers or relatively small sample sizes. Objectives: This study endeavored to describe: (i) the burden of hypothermia on admission across 21 newborn units in Kenya, (ii) any trend in prevalence of hypothermia over time, (iii) factors associated with hypothermia at admission, and (iv) hypothermia's association with inpatient neonatal mortality. Methods: A retrospective cohort study was conducted from January 2020 to March 2023, focusing on small and sick newborns admitted in 21 NBUs. The primary and secondary outcome measures were the prevalence of hypothermia at admission and mortality during the index admission, respectively. An ordinal logistic regression model was used to estimate the relationship between selected factors and the outcomes cold stress (36.0°C–36.4°C) and hypothermia (<36.0°C). Factors associated with neonatal mortality, including hypothermia defined as body temperature below 36.0°C, were also explored using logistic regression. Results: A total of 58,804 newborns from newborn units in 21 study hospitals were included in the analysis. Out of these, 47,999 (82%) had their admission temperature recorded and 8,391 (17.5%) had hypothermia. Hypothermia prevalence decreased over the study period while admission temperature documentation increased. Significant associations were found between low birthweight and very low (0–3) APGAR scores with hypothermia at admission. Odds of hypothermia reduced as ambient temperature and month of participation in the Clinical Information Network (a collaborative learning health platform for healthcare improvement) increased. Hypothermia at admission was associated with 35% (OR 1.35, 95% CI 1.22, 1.50) increase in odds of neonatal inpatient death. Conclusions: A substantial proportion of newborns are admitted with hypothermia, indicating a breakdown in warm chain protocols after birth and intra-hospital transport that increases odds of mortality. Urgent implementation of rigorous warm chain protocols, particularly for low-birth-weight babies, is crucial to protect these vulnerable newborns from the detrimental effects of hypothermia

Developing an understanding of networks in LMIC health systems: how and why networks change practices to improve service delivery and quality of care

Health systems are complex and plagued with challenges leading to poor quality of care, outcomes, and health systems functioning. Often approaches to health systems strengthening focus on tangible parts of the system. However, health systems are based on people and so are, by nature, relational. Many of the challenges are, at the root, also relational. Networks are increasingly employed to tackle health system challenges by either explicitly or implicitly targeting the relational aspects of health systems. In my DPhil, I define networks as groups of facilities and/or healthcare stakeholders that are linked with an aim to change practices to improve care and health system functioning. There is limited theory-based scholarship understanding how and why networks form, function, perform, and evolve in low- and middle-income country health systems. My DPhil addresses this knowledge gap, progressing through three linked phases. In an extensive Scoping Review, I mapped the network literature (129 manuscripts) and developed a framework of key network components. Building on this, I conducted a Realist Review developing an initial programme theory explaining how and why networks form and function to change practices. I tested this programme theory through a Realist Evaluation on the Newborn Essential Solutions and Technologies programme network in Kenya using a multiple-methods case study comprising 33 in-depth interviews, informal meetng observations, and document review. My findings are captured in a refined programme theory that explains how a network evolves through three phases: Initiation & Formation, Functioning & Performing, and Sustaining Change & Impact through interrelated: - processes (identify a problem; collective vision; taking action to solve a problem; identity and culture) - activities (knowledge and skills dissemination; cross-learning; resourcing; leadership; champions; adaptability) - foundations (teamwork; psychological safe space; commitment; engaged, motivated, empowered, and confident network members; purposeful relationships, linkages, and partnerships) - cross-cutting factors (communication; trust; energy, effort, passion). The final programme theory provides a roadmap for the relational work those employing networks should perform to promote success

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF

Background: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). Methods: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. Results: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2–34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. Conclusion: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action